What treatment is recommended for a sore throat that progressed to rhinorrhea, body weakness, and now a purulent cough after initial management with paracetamol?

Management of Viral Upper Respiratory Infection with Postinfectious Cough

This clinical presentation is consistent with a typical viral upper respiratory infection (URI) progressing to postinfectious upper airway cough syndrome (UACS), and antibiotics are NOT indicated—symptomatic treatment with first-generation antihistamine/decongestant combination is the appropriate management. 1, 2

Clinical Assessment and Diagnosis

Your symptom progression—sore throat → rhinorrhea and body weakness → purulent cough—follows the classic natural history of viral URI, where symptoms evolve over 7-14 days and purulent nasal/respiratory secretions appear after a few days without indicating bacterial infection. 1, 2

Key diagnostic principle: Purulent or discolored discharge does NOT indicate bacterial infection—it simply reflects inflammation and neutrophil presence, which is normal in viral infections. 1, 2

When to Suspect Bacterial Superinfection (NOT Present in Your Case)

Bacterial infection should only be considered if: 1, 2

• Symptoms persist beyond 10 days without any improvement, OR
• Symptoms worsen after 5-7 days (the "double sickening" pattern), OR
• Severe features develop: high fever >39°C, severe unilateral facial pain/swelling, or respiratory distress

Since you're progressing through expected viral URI stages with paracetamol already initiated, bacterial infection is highly unlikely. 1, 3

Recommended Treatment

First-Line Symptomatic Management

Initiate a first-generation antihistamine combined with a decongestant (e.g., brompheniramine with pseudoephedrine) for your cough, postnasal drip, and rhinorrhea. 4, 1, 2

This combination provides:

• More rapid improvement in cough and throat clearing compared to placebo 1
• Effective treatment for postinfectious UACS, which is what you're experiencing now 2
• Important caveat: Newer non-sedating antihistamines (like loratadine, cetirizine) are ineffective for viral URI cough and should NOT be used 4, 1

Continue Analgesics

Continue paracetamol (acetaminophen) or switch to ibuprofen/naproxen for: 1

• Sore throat relief
• Body aches and weakness
• Fever if present

Do not exceed 4000 mg paracetamol daily or take with other acetaminophen-containing products to avoid liver damage. 5

Additional Supportive Measures

• Nasal saline irrigation: Safe with low adverse effects, provides consistent improvement in nasal symptoms 1
• Oral decongestants (pseudoephedrine/phenylephrine): Effective for congestion unless you have hypertension or anxiety 1
• Avoid topical decongestant sprays beyond 3-5 days to prevent rebound congestion 1

What NOT to Do

Do NOT take antibiotics. 4, 1, 2

• Antibiotics are ineffective for viral URI and acute bronchitis regardless of cough duration or purulent sputum 4, 1
• The number needed to harm (8) exceeds the number needed to treat (18) even in bacterial sinusitis 2
• Routine antibiotic use increases antimicrobial resistance without providing benefit 4, 1

Do NOT assume persistent cough requires antibiotics or imaging. 2

• Postinfectious cough lasting 3-8 weeks is expected and self-limited 2
• Most resolve without intervention beyond symptomatic treatment 2

Expected Clinical Course

• Viral URI typically peaks within 3 days and resolves within 10-14 days 1, 3
• Cough may persist up to 10 days or longer as part of normal recovery 3
• About 90% of patients are symptom-free by one week with or without treatment 6
• Symptoms lasting beyond 10 days without improvement warrant reassessment 1, 2

Red Flags Requiring Urgent Re-evaluation

Return immediately if you develop: 2

• High fever (>39°C) returning after initial improvement
• Severe unilateral facial pain or swelling
• Severe headache with neck stiffness
• Vision changes or mental status changes
• Significant respiratory distress or difficulty breathing

Common Pitfalls to Avoid

Pitfall #1: Mistaking purulent discharge for bacterial infection—this is the most common reason for inappropriate antibiotic prescribing. 1, 2

Pitfall #2: Prescribing antibiotics based on symptom duration alone rather than trajectory (improving vs. worsening). 2

Pitfall #3: Using newer antihistamines instead of first-generation antihistamines—only first-generation agents combined with decongestants have proven efficacy for URI cough. 4, 1

Pitfall #4: Prolonged use of topical decongestant sprays leading to rebound congestion. 1